Initiative helps to improve patient throughput

Dedicated nurse is responsible for bed placement

An initiative that includes capacity alerts, "hall beds" used when the hospital is approaching capacity, and having one person responsible for coordinating bed placement has helped Spartanburg (SC) Regional Medical Center improve patient throughput and avoid being on emergency department diversion for more than a year.

"The key to our throughput initiative is having one person who owns the process and whose responsibility is to move the patients through the continuum. My goal is to be able to move patients out of the emergency department and into a bed as quickly as possible," says Stacey Hodge, RN, capacity management nurse for the hospital.

Before the hospital created the position in March 2004, department directors and case managers held lengthy bed meetings every morning to find a place for patients who were waiting for a bed. As ED case manager, Hodge attended the meetings.

"Emergency department patients were a priority, but nobody was looking ahead to see that we'd have other patients having surgery who also need beds. Bed utilization is a big concern of case managers, but it can't be the main thing they concentrate on. Everybody owned a little bit of the throughput initiative," she says.

When beds were needed, the directors called their floors to push the discharges, but it took them away from their other duties.

"When we came up with a good plan to place patients at the bed meeting, there was nobody to carry it out. Now it's my job to make sure that patient throughput flows smoothly," she says.

Hodge works closely with admissions and the nursing units throughout the hospital and reports to case management.

She monitors the hospital's bed board, a manual magnetic board that shows all the beds in the hospital with slots for the patient name, helping the clerical staff find the best bed for each patient.

"The bed board staff do not have a clinical background, and without clinical leadership they may not choose the bed that is best for the patient. I stay close to the bed board because it changes so quickly," she says.

For instance, if the orthopedic unit's capacity is high and a patient with a fractured hip comes in, a patient may have to be moved off the orthopedic floor.

"Our goal is to get the right patient in the right bed the first time so we don't have to move them around later," she says.

The clerical staff cover the bed board 24 hours a day, seven days a week. All requests for beds from physician offices, other hospitals, the ED, or the surgery department come into the bed board staff.

The bed board office gets a list of all patients being scheduled for surgery each day. "Depending on the procedures they're having, we can get a good idea of who is staying," Hodge says.

Each morning, the case managers on the floor send an e-mail alerting the bed board staff of anticipated discharge.

"This gives us a starting point to manage capacity for the day. If they have three beds available and we have five patients in surgery who need to go to that floor, I push to get more patients discharged," Hodge reports.

The bed board staff are alerted when transportation is notified that a patient is ready for discharge. If the bed is needed immediately, the bed board staff notify housekeeping to clean the room immediately.

Spartanburg Regional Medical Center has created what it calls a Red Capacity Alert that notifies the staff that the hospital is approaching capacity.

When the hospital goes on Red Capacity Alert, it is announced over the hospital's intercom, alerting staff that the census has reached a critical level and that the likelihood of having to place patients in hall beds has increased tremendously, Hodge says.

Criteria for a Red Capacity Alert are:

  • two patients holding in a holding area with no bed assignment for longer than an hour.
  • two patients holding in a holding area with a bed assignment but who have not been moved to the bed within two hours.

Holding areas include the emergency department, recovery, and catheterization lab.

"We have guidelines for Yellow Capacity Alert when there is one patient in either situation, but we rarely use it. When we have one patient without a bed, we usually have two," she said.

As part of the initiative to improve patient throughput, the hospital has created eight hall beds on the medical-surgical and cardiac care floors. The beds are in an alcove near the nursing station with a curtain for privacy.

When the floor is totally full, patients who are stable can be moved into a hall bed.

"We have strict criteria about patients who can be in hall beds. They can't have nausea or vomiting or be on oxygen. They have to be mobile, because they have to walk down the hall to the bathroom. If we need a bed, we often move someone close to discharge to the hall bed," Hodge says.

Patients rarely stay in a hall bed more than a few hours. The exception has been during the influenza and pneumonia season when some patients have stayed in a hall bed overnight.

"Once we start using the hall beds, it heightens everybody's awareness and they work to ensure that the patients who are ready to go home can be discharged," Hodge says.

The hospital uses hall beds only on rare occasions when there is a critical need for beds.

"There were a lot of concerns about the hall bed system, and we looked at all of those before we set them up. Our main focus is the welfare of the patient, and having one nurse on the floor take care of one extra patient makes more sense than having the emergency center nurses take care of a lot of extra patients," she says

Hodge works 7:30 a.m. to 4 p.m. Monday through Friday, during the peak times for patient placement. When she's not in the hospital, the house supervisor takes over her job. Usually by the time Hodge leaves, all of the surgical patients have been placed and calls from physician offices have decreased.

Hodge works closely with the staff on the floors to maximize bed capacity, going to the units and walking the floors looking for beds that may be available soon. Part of her role is to help staff understand the need to get patients discharged as quickly as possible.

When you're on the floor, you see only your world. I can stand at the bed board and see the big picture. When the nurse manager or charge nurse feel like they're being pushed, they don't always like it but they do understand it," she says.

Hodge oversees the transfer of patients on the medical-surgical floor to the critical care unit.

"If a nurse notifies us that a patient needs a bed on the unit and the physician isn't there, I go to the floor and look at the patient to back up the nurse's call," she says.

Hodge mediates between floors in an effort to keep outliers from being moved from floor to floor.

"We have patients with long length of stay and nowhere to go. I try to keep from moving the patients with the long length of stay so they don't get lost in the flow," she says.

Patient throughput has a domino effect on everything the hospital does, Hodge points out.

"If we can't get patients out of recovery and into a room, we have to stop surgery, and that has a major effect on our revenue. That's happened only once since we started this system and only for half and hour," she says.

The hospital has not been on emergency department diversion for more than a year.

"Our administration makes a tremendous effort to avoid being on diversion whenever possible. We are the largest hospital in the area. Smaller hospitals need to feed patients to us for care that they can't provide. We have to be accessible for them," she says.

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